FDA Adverse Event Other Summary report: N

TRUEBALANCE BLOOD GLUCOSE MONITOR

MDR report key: 3365772 · Received September 19, 2013

Report

Report Number
MW5031979
Event Type
Other
Date Received
September 19, 2013
Date of Event
August 27, 2013
Report Date
September 18, 2013
Manufacturer
NIPRO DIAGNOSTICS
Product Code
NBW
Report Source
Voluntary report
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Description of Event or Problem · 1

DISPARITY FOUND IN CERTAIN TRUEBALANCE BLOOD GLUCOSE MONITORING SYSTEM ("BGM"), MANUFACTURED BY NIPRO DIAGNOSTICS RECENTLY PURCHASED, WHERE THE RESULTS DISPLAYED ARE IN MMOL/L INSTEAD OF MG/DL AS PREFERRED IN THE UNITED STATES. AS PER THE TRUEBALANCE USER MANUAL, THIS SETTING IS FIXED BY THE MANUFACTURER AND CANNOT BE CHANGED BY THE CONSUMER. DETERMINING THE TYPE OF UNIT FROM THE PACKAGING ALONE IN NOT POSSIBLE, A TEST MUST BE DONE ON EACH UNIT INDIVIDUALLY. WHEN TESTING, THE MMOL/L RESULTS ARE MUCH LOWER THAN MG/DL RESULTS AND ARE DISPLAYED AS DECIMALS (5.5 MMOL/L OR 100 MG/DL). THIS COULD LEAD TO GREAT CONFUSION WITH OUR DIABETIC PTS, MANY OF WHICH ARE ELDERLY, WHO MAY NOT NOTICE THE DECIMAL POINT AND BASE THEIR TREATMENT ON THE INCORRECT RESULTS (E.G. 13.5 MMOL/L READ AS 135 MG/DL, ACTUAL RESULTS 243 MG/DL). WE IMMEDIATELY NOTIFIED THE VENDOR ON (B)(4), 2013. WE ARE IN THE PROCESS OF IDENTIFYING ALL LOT NUMBERS OF TRUEBALANCE MONITORS PURCHASED IN THE MONTHS OF (B)(4), HOWEVER, AT THIS MOMENT IN OUR INVESTIGATION WE HAVE BEEN ABLE TO SINGLE OUT LOT # KP0128TI WITH EXPIRATION DATE 1/31/2015 TO BE THOSE UNITS DISPLAYING RESULTS IN MMOL/L, AS WELL AS UNITS WITH CORRECTS RESULTS IN MG/DL. WE ARE NOT AWARE OF ANY ADVERSE OUTCOMES TO PTS AT THIS TIME, HOWEVER, THIS HAS THE POTENTIAL TO ADVERSELY AFFECT OVER (B)(4).

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
474451 TRUEBALANCE BLOOD GLUCOSE MONITOR TRUEBALANCE NBW NIPRO DIAGNOSTICS KP0128TI

Patients

Seq Age Sex Outcome Treatment
1 Other